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Welcome to the 66th Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.

Unfortunately, this week's research studies aren't the greatest, being either retrospective, post hoc, meta analytic or small in nature. This week's guidelines focus on warfarin reversal and haemostatic assessment pre-operatively. There are three study critiques and a number of editorials on sepsis and one on the declining rates of stroke mortality.

Research

Critical Care: Non-Invasive Ventilation Post-Extubation

Ornico completed a small single centre, randomized, prospective, controlled, unblinded clinical study to compare non-invasive ventilation (NIV, n=20) applied immediately after planned extubation with oxygen mask (OM, n=20) in patients with acute respiratory failure. The rate of re-intubation was lower in the NIV group (5% versus 39%; p=0.016, relative risk for re-intubation 0.13; CI=0.017-0.946). There was an absolute risk reduction for re-intubation of 33.9% (NNT 3). Although there was no difference in the length of ICU stay (p=0.681), hospital mortality was 0% in NIV group and 22.2% in OM group (p= 0.041). Conclusion: In a small, single centre, unblinded study the use of immediate NIV post extubation was associated with reduced reintubation rates and improved mortality when compared with oxygen mask therapy

Chest: Vasopressor Therapy

To characterize survival among patients with shock requiring high-dose vasopressor (HDV) therapy, Brown et al conducted a multi-centre retrospective study of patients with shock requiring HDV, with HDV defined as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). Of 443 patients, 76 (17%) survived, with a similar survival amongst the 241 patients (20%) with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = 0.01). Conclusion: One in six patients with shock survived to 90 days after HDV; stress-dose corticosteroid therapy was associated with improved survival.

Elke and colleagues undertook a secondary analysis of the VISEP study to compare three nutritional strategies—enteral (EN), parenteral (PN), and combined nutrition (EN+PN)—on the outcome of patients with severe sepsis or septic shock. Only patients with an ICU length of stay of more than 7 days were included (n=353). 68.5 % received EN+PN, 24.4 % received EN, and only 7.1 % received PN. Median caloric intake was 918 kcal/day (EN), 1,210 kcal/day (PN), and 1,343 kcal/day (EN+PN; p < 0.001). In the latter group, calories were predominantly administered via the parenteral route within the first week. The rate of death at 90 days was lower with EN than with EN+PN (26.7 % vs. 41.3 %, p = 0.048), as was the rate of secondary infections, renal replacement therapy, and duration of mechanical ventilation. In the adjusted Cox regression analysis, the effect on mortality [hazard ratio = 1.86, 95 % CI: 1.16–2.98; p = 0.010] and the rate of secondary infections (HR = 1.89, 95 % CI: 1.27–2.81; p = 0.002) remained different between EN and EN+PN. Conclusion: In this secondary analysis of the VISEP study, in patients with severe sepsis or septic shock and prolonged ICU stay, the administration of EN alone was associated with improved clinical outcome compared to EN+PN.